Authors: Andrew Solomon
Indigence is a good trigger for depression; relief of indigence is a good trigger for recovery. The focus of liberal politics has been on ameliorating the external horrors of indigent lives, with the assumption that this will make people happier. That goal should never be discounted. It is sometimes more feasible, however, to relieve the depression than to fix the indigence. Popular wisdom holds that unemployment must be remedied before the fancy business of the mental health of the unemployed is addressed. This is poor reasoning; fixing the mental health problem may well be the most reliable way to return people to the workforce. In the meanwhile, some advocates for the disenfranchised have worried that Prozac will be added to the tap water to help the miserable tolerate the intolerable. Unfortunately, Prozac neither makes nor keeps the miserable happy, and so the paternalistic totalitarian scenario sketched by social alarmists has no basis in reality. Treating the consequences of social problems will never substitute for solving them. Indigent people who have received appropriate treatment may, however, be able to work in concert with liberal politics to change their own lives, and those changes can cause a shift in the society as a whole.
Humanitarian arguments for treating depression among the indigent are sound; the economic arguments are at least equally sound. Depressed people are an enormous strain on society: 85 to 95 percent of people in the United States with serious mental illness are unemployed. Though many of them struggle to lead socially acceptable lives, others are given to substance abuse and self-destructive behaviors. They are sometimes violent. They pass these problems on to their children, who are likely to be mentally slow and emotionally dysfunctional. When a poor depressed mother is not treated, her children tend to head into the welfare and prison systems: the sons of mothers with untreated depression are far more likely to become juvenile delinquents than are other children. Daughters of depressed mothers will go through puberty earlier than other girls, and this is almost always associated with promiscuity, early pregnancy, and emotional instability. The dollar cost of treating depression in this community is modest when compared to the dollar cost of not treating depression.
It is extremely difficult to find any poor people who have had sustained treatment for depression, because there are no coherent programs in the United States for locating or treating depression in this population.
Medicaid recipients qualify for extensive care but have to claim it, and depressed people seldom exercise rights or claim what should be theirs, even if they have the sophistication to recognize their condition. Aggressive outreach programs—which seek out people who may need treatment and bring that treatment to them, even if such people are disinclined to pursue help—are morally justified, because those seduced into treatment are almost always glad to have received such attention; here more than elsewhere, the resistance is a symptom of the illness. Many states promise more or less adequate treatment programs for those among the indigent depressed who are able to visit the appropriate offices, fill in the appropriate forms, wait in the right lines, provide three kinds of photo identification, research and enroll in programs, and so on. Few indigent depressed people have these capacities. The social status and serious problems of the indigent depressed make it virtually impossible for them to function at this level. This population can be treated only by addressing illness before addressing the passivity with which they tend to experience that illness. Speaking of mental health intervention programs, Steven Hyman, director of the NIMH, says, “It’s not like the KGB rolling up in a bread truck and pulling you in. But you need to pursue these people. You could do this in the workfare programs. If you want to have the most effective transition from welfare to work, that is a good place to start. It is probably an unprecedented experience in these people’s lives to have somebody really interested in them.” Most people are initially uncomfortable with unprecedented experiences. Desperate people who dislike help are usually unable to believe that help will set them free. They can be saved only through muscular exhortation of missionary zeal.
It is hard to make specific numerical estimates of the costs associated with serving this population, but 13.7 percent of Americans are below the poverty line, and according to one recent study, about 42 percent of heads of households receiving Aid to Families with Dependent Children (AFDC) meet the criteria for clinical depression—more than twice the national average. A staggering 53 percent of pregnant welfare mothers meet the same criteria. From the other side, those with psychiatric disorders are 38 percent more likely to receive welfare than are those without. Our failure to identify and treat the indigent depressed is not only cruel but also expensive. Mathematica Policy Research, Inc., an organization that compiles social-issue statistics, confirms that “a substantial proportion of the welfare population . . . have undiagnosed and/or untreated mental health conditions,” and that offering services to these individuals would “enhance their employability.” State and federal governments spend roughly $20 billion per year on cash transfers to poor nonelderly
adults and their children. We spend roughly the same amount for food stamps for such families. If one makes the conservative estimate that 25 percent of people on welfare are depressed, that half of them could be treated successfully, and that of that percentage two-thirds could return to productive work, at least part-time, factoring in treatment costs, that could still reduce welfare costs by as much as 8 percent—a savings of roughly $3.5 billion per year. Because the U.S. government also provides health care and other services to such families, the true savings could be substantially higher. At the moment, welfare officers do no systematic screening for depression; welfare programs are essentially run by administrators who do little social work. What tends to be described in welfare reports as apparently willful noncompliance is in many instances motivated by psychiatric trouble. While liberal politicians tend to emphasize that a class of miserable poor people is the inevitable consequence of a laissez-faire economy (and is therefore not subject to rectification through mental health interventions), right-wingers tend to see the problem as one of laziness (which is therefore not subject to rectification through mental health interventions). In fact, for many of the poor, the problem is neither the absence of employment opportunities nor the absence of motivation toward employment, but rather severe mental health handicaps that make employment impossible.
Some pilot studies are under way on depression among the indigent. A number of doctors who work in public health settings are accustomed to addressing this population, and they have shown that the problems of the indigent depressed are manageable. Jeanne Miranda, a psychologist at Georgetown University, has for twenty years been advocating sound mental health care for inner-city residents. She recently completed a treatment study of women in Prince George’s County, Maryland, a poverty-stricken district outside Washington, D.C. Since the services of family planning clinics are the only medical care available to the indigent population in Maryland, Miranda selected one for random screenings for depression. She then enrolled those whom she judged to be depressed in a treatment protocol to address their mental health needs. Emily Hauenstein, of the University of Virginia, has recently conducted a treatment study of depression among rural women. She began researching troubled children and moved on to treating their mothers. She based her work in Buckingham County in rural Virginia—where most jobs are at prisons or in a few factories, where a good part of the population is illiterate, where a quarter of the population has no access to a telephone, where many people live in substandard housing with no insulation, no indoor toilet, frequently not even running water. Both Miranda and Hauenstein screened substance abusers out of their protocols, referring them to
rehabilitation programs. Glenn Treisman, of the Johns Hopkins University Hospital, has for decades been studying and treating depression among indigent HIV-positive and AIDS populations in Baltimore, most of whom are also substance abusers. He has become both a treating clinician and an outspoken advocate for this population. Each of these doctors uses techniques of tenacious care. In all of this work, the per patient per year cost is well under $1,000.
The results of these studies are surprisingly consistent. I was given full access to patients in all of these studies, and to my surprise, everyone I met believed that his or her life had improved at least a bit during treatment. All those who had recovered from severe depression, no matter how dreadful their circumstances, had begun the slow climb toward functioning. They
felt
better about their lives and also lived better. They had been introduced to agency and had begun to exercise it; even when they were up against nearly insurmountable obstacles, they progressed—often fast, and sometimes far. The horrible stories of their lives were way beyond anything I had anticipated, so much so that I repeatedly checked the stories with their treating doctors, asking whether they could really be accurate. So too were their Cinderella-like stories of recovery, as lovely as the one with the pumpkin coach and the glass slipper. Over and over again, as I met poor people who were being treated for depression, I heard tones of astonishment and wonder: How, after so many things had gone wrong, had they been swept up by this help that had changed their entire life? “I asked the Lord to send me an angel,” said one woman, “and he answered my prayers.”
When Lolly Washington—who was part of Jeanne Miranda’s study—was six, a disabled friend of her alcoholic grandmother’s began abusing her sexually. In seventh grade, “I felt there was no reason to go on. I did my schoolwork and everything, but I was not happy in any way.” Lolly began to withdraw. “I would just stay to myself. Everyone thought I couldn’t talk for a while, because for a few years there I wouldn’t say anything to no one.” Like many victims of abuse, Lolly believed herself to be ugly and unfit. Her first boyfriend was physically and verbally brutal, and after the birth of her first child, when she was seventeen, she managed to “escape from him, I don’t know how.” A few months later she was out with her sister and her cousin and her cousin’s child and an old family friend “who was always just a friend, a really good friend. We were in his house, all of us, and I knew his mom kept pretty flower arrangements on her dresser. So I went to look at them because I loved flowers. And then suddenly, somehow everybody in the house was gone, and I didn’t know. He raped me, violent, and I was screaming and hollering
and no one answered. Then we went downstairs and we got into the car with my sister. I couldn’t speak, I was so afraid, and bleeding.”
Lolly became pregnant with and bore the rape baby. Soon after, she met another man and under family pressure married him even though he too was abusive. “My whole wedding day was not right,” she told me. “It was like going to a funeral. But he was the best option I had.” She had three more children by him in the next two and a half years. “He was abusing the children too, even though he was the one who wanted them, cursing and yelling all the time, and the spankings, I couldn’t take that, over any little thing, and I couldn’t protect them from it.”
Lolly began to experience major depression. “I’d had a job but I had to quit because I just couldn’t do it. I didn’t want to get out of bed and I felt like there was no reason to do anything. I’m already small and I was losing more and more weight. I wouldn’t get up to eat or anything. I just didn’t care. Sometimes I would sit and just cry, cry, cry. Over nothing. Just cry. I just wanted to be by myself. My mom helped with the kids, even after she got her leg amputated, which her best friend accidentally shot off around then. I had nothing to say to my own children. After they left the house, I would get in bed with the door locked. I feared when they came home, three o’clock, and it just came so fast. My husband was telling me I was stupid, I was dumb, I was ugly. My sister has a problem with crack cocaine, and she has six kids, and I had to deal with the two little ones, one of them was born sick from the drugs. I was tired. I was just so tired.” Lolly began to take pills, mostly painkillers. “It could be Tylenol or anything for pain, a lot of it though, or anything I could get to put me to sleep.”
Finally one day, in an unusual show of energy, Lolly went to the family planning clinic to get a tubal ligation. At twenty-eight, she was responsible for eleven children, and the thought of another one petrified her. She happened to go in when Jeanne Miranda was screening for study subjects. “She was definitely depressed, about as depressed as anyone I’d ever seen,” recalls Miranda, who swiftly put Lolly into group therapy. “They told me I was ‘depressed,’ and that was a relief, to know there was something specific wrong,” Lolly says. “They asked me to come to a meeting, and that was so hard. I didn’t talk when I went there, but I just cried the whole time.” Psychiatric wisdom holds that you can help only those who want to be helped and will keep their appointments themselves, but this is ostentatiously untrue in these populations. “Then they kept calling, telling me to come, pestering and insisting, like they wouldn’t let go. They even came and got me at my house once. I didn’t like the first meetings. But I listened to the other women and realized that they had the same problems I was having, and I began to tell them
things, I’d never told anyone those things. And the therapist asked us all these questions to change how we thought. And I just felt myself changing, and I began to get stronger. Everyone began to notice I was coming in with a different attitude.”
Two months later, Lolly told her husband that she was leaving. She tried to get her sister into rehab, and when she refused, Lolly cut her off. “I had to get rid of them two who were pulling me down. There was no arguing because I just didn’t argue back. My husband was trying to get me out of the group because he didn’t like the change in me. I just told him, ‘I’m gone.’ I was so strong, I was so happy. I went outside to walk, for the first time in so long, just making time for my happiness.” It took two more months for Lolly to find a job, working in child care for the U.S. Navy. With her new salary, she set up in a new apartment with the children for whom she is responsible, who ranged in age from two to fifteen. “My kids are so much happier. They want to do things all the time now. We talk hours every day, and they are my best friends. As soon as I come in the door, I put my jacket down, purse, and we just get out books and read, doing homework all together and everything. We joke around. We all talk about careers, and before they didn’t even think careers. My eldest wants to go to the air force. One wants to be a firefighter, one a preacher, and one of the girls is gonna be a lawyer! I talk to them about drugs, and they’ve seen my sister, and they keep clean now. They don’t cry like they used to and they don’t fight like they did. I let them know, they can talk to me about anything, I don’t care what it is. I took in my sister’s kids, and the one with the drug problem, he’s getting over it. The doctor said he never expected that boy could be talking so soon, trying to get to the potty, he’s way ahead of where they thought he’d be.